The Washington Post

Paul Ryan and the moral argument for rationing health care

 As a vice presidential candidate, Paul Ryan (R-Wis.) appears to have made our polarized politics even worse. After all, what could be more polarizing than his serious attempt to reform the third rail of politics: entitlement programs like Medicare and Medicaid? But Ryan actually provides an important opportunity for a real conversation about making hard choices about health care—one that our culture desperately needs to have.

Republican vice presidential candidate Paul Ryan (Wis.). Washington Post

Ryan’s stated motivation for his proposed changes to Medicare and Medicaid is the “preferential option for the poor”—something he correctly calls one of the primary principles of his Catholic Church’s social teachings. 

Armed with powerpoints and virtually unlimited energy, Ryan has become a tour de force in raising awareness about the radical unsustainability of our country’s health care system. It is already putting a massive strain on our economy—and with increasing health care costs, coupled with far fewer workers paying taxes relative to those in retirement, things are looking to get much worse before they get better.

Here in the United States, Medicare trustees say that if something isn’t done the system will go broke sometime around 2024. Ryan quite rightly insists that it is a moral imperative to do something to save the system to make it sustainable for future generations so those who need these safety nets will have them. The alternative, he says, are the strict austerity measures of Greece, Spain, Italy and other countries—and this will hurt the poor far more than reforming the system in the ways he has proposed. His well-known plan is to privatize Medicare and Medicaid and drive down the cost curve in an attempt to save the U.S. government (and the several states) from trillions in unfunded health care liabilities that would otherwise force us to abandon this programs altogether.

Catholic teaching agrees with him about intergenerational solidarity—especially with the poor—but Ryan must face the fact that his Church also claims that there is a right to health care. Like food, shelter, education and other basic needs, human dignity requires that the community provide health care to all. And because respecting this right seems to go beyond the abilities of local, private organizations, subsidiarity has led the U.S.Conference of Bishops to support “truly universal and genuinely affordable” health care—something they have done for many decades. It appears that Ryan does not accept this teaching, especially because his plan to reform Medicare would cost seniors so much money that many of them would be unable to afford such insurance at all.

The only moral option left to us, at least if we accept a right to health care, is to ration health care.

More precisely, we should more carefully, justly, explicitly and honestly continue to ration health care. Even private insurance rations care based on preexisting conditions, ability to pay, and negotiates deals with hospitals and physicians for how much (almost never 100 percent) of the bill they will pay. Medicaid and Medicare have a “CMS” office whose job it is to ration care. They decide whether to reimburse for a procedure at all, and then, if they do reimburse, they also decide at what percentage they will reimburse. Some procedures are denied altogether, and some rates of reimbursement (like prenatal care for women) are incredibly low.

It may be shocking to think about at first, but upon reflection it is difficult to see how it could be otherwise. Given that we have virtually unlimited health care needs and dramatically limited resources, we will never not be rationing health care.

I have argued elsewhere that rationing health care is also perfectly consistent with Catholic teaching. “Aiming at death” because one wants someone dead is always going to be wrong, but that is a very different kind of act from deciding how to justly allocate scarce health care resources. Interestingly, though they opposed the recent health care reform bill on the basis of it paying for procedures which aimed at the death of prenatal children, the Conference of Bishops did not oppose it on the basis of rationing or “death panels”—despite other pro-life groups doing so. Catholics have a tradition which, while it will never accept murder, it also will never make life’s preservation into an idol which trumps God’s justice and love. Our tradition of martyrdom is evidence of that.

Ryan should be genuinely admired, especially by liberals who care about vulnerable populations, for having the courage to squarely face our looming health care debt crisis which threatens to devastate future vulnerable populations. While he clearly understands the problem, he does not appear to have the correct solution—especially if he accepts Catholic teaching on the duty of our society to provide health care to all.

Charles C. Camosy is professor of Christian Ethics at Fordham University in New York City. His most recent book is “Peter Singer and Christian Ethics: Beyond Polarization,”  and he contributes to

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